New Application Only.doc.doc

THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org

FOR NEW APPLICATIONS ONLY – PEDIATRIC NEPHROLOGY

GENERAL INSTRUCTIONS

APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with the Web Accreditation Data System).

All sections of the form applicable to the program must be completed in order to be accepted for review. The information provided should describe the proposed program. For items that do not apply indicate N/A in the space provided. Where patient numbers are requested, estimate what you expect will occur. If any requested information is not available, an explanation should be given and it should be so indicated in the appropriate place on the form.

Once the forms are complete, number the pages sequentially in the bottom center. Send four complete copies to the executive director of the Residency Review Committee for Pediatrics at the address above. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding.

The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution.

Review the Program Requirements for Residency Education in Pediatric-Nephrology. The Program Requirements and the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org):

For questions regarding:

-the completion of the form (content), contact the Accreditation Administrator.

-the Accreditation Data System, email [email protected].

For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

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http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp

Attach the following documents to the application:

References to Common Program and Institutional Requirements are in parenthesis

1. Policy for supervision of residents (addresses residents’ responsibilities for patient care and progressive responsibility for patient management and faculty responsibilities for supervision) (CPR IV.A.4.; IR III.B.4.)

2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.j.4.; CPR VI.C.; IR II.D.4.i.; IR III.B. 3.)

3. Moonlighting policy (CPR VI.F.1-2; CPR II.A.4.j.; IR II.D.4.j.)

4. Overall educational goals for the program (CPR IV.A.1.)

5. A sample of competency-based goals and objectives for one assignment at each educational level (CPR IV. A. 2.)

6. All Program Letters of Agreement (PLAs) (CPR I.B.1.)

7. A blank copy of the forms that will be used to evaluate residents at the completion of each assignment (CPR V.A.1.a.)

8. Copies of tools the program will use to provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (CPR V.A.1.b.(1))

9. A blank copy of the form that will be used to document the semiannual evaluation of the residents with feedback (CPR V.A.1.b.(2) & (4))

10. A blank copy of the final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2.)

11. A blank copy of the form that residents will use to evaluate the faculty (CPR V.B. 3.)

12. A blank copy of the form that residents will use to evaluate the program (CPR V.C.1.d.(1))

Single Program Sponsors only:

1. A copy of the resident contract with the pertinent items from the institutional requirements and Master Affiliation Agreements

2. Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A.)

3. Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e.; IR III.B.7.)

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Program Name:

TABLE OF CONTENTS

When you have the completed forms, number each page sequentially in the bottom center. Record this pagination in the Table of Contents and submit this cover page with the completed PIF.

Common PIF Page(s)Accreditation Information

Response to Previous CitationsParticipating Sites

Single Program Sponsoring Institutions (If applicable)Program Personnel and Resources

Program Director InformationPhysician Faculty RosterFaculty Curriculum VitaeNon Physician Faculty RosterProgram Resources

Resident AppointmentsEvaluation (Residents, Faculty, Program)Resident Duty HoursResident Scholarly Activities

Pediatric Subspecialty PIF Page(s)Faculty ResearchResearch ResourcesProgram Curriculum

Block DiagramGoals and ObjectivesCollaboration Between ProgramsGeneral Subspecialty CurriculumConferencesScholarship Oversight CommitteeFellow Research Activities

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Specialty Specific PIF Page(s)Personnel, Facilities and Resources

Support ServicesFacilitiesServices and Laboratories

Patient CarePatient Data Ambulatory Pediatric Nephrology Experience for All Years of Training for New Applications12-Month Summary - Inpatient Services36 Month Summary: Patient ProceduresList of Diagnoses

Medical KnowledgeCore Curriculum: Specialty ExperiencesInpatient ExperiencesOutpatient Experiences

Practice-based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-based Practice

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PROGRAM INFORMATION FORM – PEDIATRIC NEPHROLOGY

A. ACCREDITATION INFORMATION

Date:

Title of Program:

Requested Effective Date of Accreditation:

Length of program:

Number of requested resident positions:

Core Program Information

Title of Core Program:

10 Digit ACGME Program ID#:

The signatures of the director of the program and the designated institutional official attest to the completeness and accuracy of the information provided on these forms.

Name of Program Director:

Signature of Program Director (and date):

Name of Core Program Director:

Signature of Core Program Director (and date):

Name of Designated Institutional Official (DIO):

Signature of DIO (and date):

1. Respond to Previous Citation(s)

If the program reapplies for accreditation within two years after accreditation has previously been withdrawn or proposed withdrawn, the accreditation history of the last accreditation action of that program shall be included as part of the file.

a) In the case of application after proposed withdrawal, provide a statement rebutting each citation and documenting compliance with ACGME Requirements or provide a response to b) below.

b) In case of application after either proposed withdrawal or withdrawal, provide a statement of the measures the program has taken to comply with ACGME Requirements relating to each citation in the last letter of accreditation.

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B. PARTICIPATING SITES

SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NOCity, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Name of Designated Institutional Official: Mailing Address: Phone Number:

Email: Name of Chief Executive Officer: Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)?

( ) YES ( ) NO

If yes, name the medical school below and have an affiliation agreement that describes the effect of these arrangements on this program available. Name of Medical School #1: Name of Medical School #2:

PRIMARY CLINICAL SITE (Site #1) Name:Address:City, State, Zip Code:Clinical Site? ( ) YES ( ) NOType of Rotation (select one)

Elective ( ) Required ( ) Both ( )

Length of Resident/Fellow Rotations (in months) Year 1: Year 2: Year 3:CEO/Director/President’s Name: Joint Commission Approved? ( ) YES ( ) NO If no, explain:

The Program Director must submit any participating sites routinely providing an educational experience, required for all residents, of one month full time equivalent (FTE) or more. Duplicate as necessary. PARTICIPATING SITE (Site #2) Name:Address:City, State, Zip Code:Integrated: ( ) YES ( ) NODoes this site also sponsor its own program in this specialty? ( ) YES ( ) NODoes it participate in any other ACGME-accredited programs in this specialty? ( ) YES ( ) NODistance between #2 & #1:

Miles: Minutes:

Type of Rotation (select one)

( ) Elective ( ) Required ( ) Both

Length of Resident/Fellow Rotations (in months) Year 1: Year 2: Year 3:CEO/Director/President’s Name:Brief Educational Rationale:

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1. SINGLE PROGRAM SPONSORING INSTITUTIONS (if applicable)

For those institutions which are either a single-program sponsoring institution (e.g., medical genetics only), or an institution with multiple residencies accredited by the same Residency Review Committee (RRC), the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions.

a) Provide an institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2)

b) Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how residents and faculty in the program are involved in the evaluation process. (CPR V.C; IR IV)

c) Describe how the institution complies with the Institutional Requirements regarding “Resident Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of residents in accordance with the Program and Institutional Requirements. (IR II.A-B)

d) Summarize how the institution complies with the ACGME Institutional Requirements regarding resident support, benefits and conditions of employment to include the details of the resident contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the resident contract/agreement to the PIF but state when it is given to the residents and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.) (IR II.C-D)

e) Describe in detail the grievance (due process) procedure(s) that is available to residents, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a resident’s contract, or other actions that could significantly threaten a resident’s intended career development. (IR II.D.4.c-d)

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C. PROGRAM PERSONNEL AND RESOURCES

1. Program Director Information

Name: Title: Address: City, State, Zip code:Telephone: FAX: Email:Date First Appointed as Program Director: Will Your Principal Activity Be Devoted to Resident Education? ( ) YES ( ) NOTerm of Program Director Appointment: Date first appointed as faculty member in the program:Percentage of time the program director devotes to the program in the following activities:Clinical Supervision:

Administration: Research: Didactics/Teaching:

Primary Specialty Board Certification: Most Recent Year:Secondary Specialty Board Certification: Most Recent Year: Number of years spent teaching in GME in this specialty:

a) Does the program director approve the selection of program faculty as appropriate?..............................................................................................................................( ) YES ( ) NO

b) Will the program director evaluate the faculty and approve the continued participation of program faculty based on evaluation?.................................................................................( ) YES ( ) NO

c) Will the program director comply with the sponsoring institution’s written policies and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents?................................( ) YES ( ) NO

d) Is the program director familiar with and does he/she comply with ACGME and RC policies and procedures as outlined in the ACGME Manual of Policies and Procedures? ......( ) YES ( ) NO

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2. Physician Faculty Roster

(1) First list the Program Director, followed by the other Pediatric Nephrology subspecialists. Also identify any research mentors who participate in training. Identify that they are research mentors by indicating so in the faculty member’s title, (e.g., Associate Professor/Research Mentor). Using the form provided, attach a one page CV for each faculty member under this subspecialty only.

Then identify at least one faculty member in the following disciplines. Faculty should be listed in the following order:

(2) Appropriate teaching and consultant faculty in the full range of pediatric subspecialties should be available to the program, list those subspecialists here. (Pediatric Cardiology, Pediatric Critical Care, Pediatric Emergency Medicine, Pediatric Endocrinology, Pediatric Gastroenterology, Pediatric Hematology/Oncology, Pediatric Infectious Diseases, Neonatal-Perinatal Medicine, Pediatric Pulmonology, Pediatric Rheumatology).

(3) Other critical specialists/subspecialties as appropriate to Pediatric Nephrology should be listed next. (Allergy/Immunology, Anesthesiology, Child Neurology, Medical Genetics, Pathology, Pediatric Surgery, Psychiatry, Psychiatry, Pediatric Radiology, Pediatric Urology, Transplantation). For clarification on which subspecialties are considered critical, refer to PR for Pediatric Nephrology. Do not include CVs of other subspecialists, unless they are not ABMS-certified.

Name (Position)Degre

e

Based Primarily at Site #

Primary and Secondary Specialties / Field

Years as Faculty

in Specialt

y

Average Hours Per

Week Devoted

to Resident

EducationSpecialty /

Field

Board Certificatio

n (Y/N)†

Most Recent

Certification Date

(PD)

† Certification for the primary specialty refers to ABMS Board Certification. Certification for the secondary specialty refers to sub-Board certification. If the secondary specialty is a core ACGME specialty (e.g., Internal Medicine), the certification question refers to ABMS Board Certification.

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3. Faculty Curriculum Vitae

First Name:

MI:Last Name:

Present Position:Medical School Name:Degree Awarded:

Year Completed:

Graduate Medical Education Program Name(s); include all residencies and fellowships:

Specialty/FieldDate From:

To:

Certification and Re-Certification Information Current Licensure Data

SpecialtyCertification Year

Re-Certification Year

State Date of Expiration

Academic Appointments - List the past ten years, beginning with your current position. Start Date End Date Description of Position(s)

Present

Concise Summary of Role in Program:

Current Professional Activities/Committees:

Selected Bibliography - Most representative Peer Reviewed Publications/Journal Articles from the last 5 years (limit of 10): Selected Review Articles, Chapters and/or Textbooks (Limit of 10 in the last 5 years):

Participation in Local, Regional, and National Activities/Presentations (Limit of 10 in the last 5 years):

If not ABMS board certified, explain equivalent qualifications:

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4. Non Physician Faculty Roster

List alphabetically the non-physician faculty who provide required instruction or supervision of residents in the program.

Name (Position) Degree

Based Primarily at

Site # Specialty / Field Role In Program

Years as Faculty in Specialty

5. Program Resources

a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach residents? Mention time spent in activities such as conferences, rounds, journal clubs, etc. if relevant.

b) Briefly describe the educational and clinical resources available for resident education.[The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.]

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D. RESIDENT APPOINTMENTS

Total Number of Requested Positions

1. Describe how residents will be informed about their assignments and duties during residency. [The answer must confirm that there are goals and objectives for each assignment and for each year, and that these will be readily available (hard copy, electronically, listserv, etc.) to all residents.]

2. Will there be other learners (such as residents from other specialties, subspecialty fellows, nurse practitioners, PhD or MD students) in the program, sharing educational or clinical experiences with the residents? If yes, describe the impact those other learners will have on the program’s residents.

3. Describe how the program will handle complaints or concerns the residents raise. (The answer must describe the mechanism by which individual residents can address concerns in a confidential and protected manner as well as steps taken to minimize fear of intimidation or retaliation.)

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E. EVALUATION (RESIDENTS, FACULTY, PROGRAM)

1. Will residents be evaluated on their performance following each learning experience?..............................................................................................................................( ) YES ( ) NO

If no, explain

2. Will these evaluations be documented (in written or electronic format)?..............( ) YES ( ) NO

If no, explain

3. Using the table below (add rows as needed):

a) provide the methods of evaluation used for assessing resident competence in each of the six required ACGME competencies and,

b) identify the evaluators for each method (e.g., “performance in patient care is evaluated by global forms completed by faculty and senior residents, observed histories and physicals by the ward attending and the continuity preceptor; medical knowledge is assessed through the In-Training Examination and an evidence-based journal club evaluated by the PD, etc.”)

Examples of assessment methods: direct observation, videotaped/recorded assessment, global assessment, simulations/models, record/chart review, standardized patient examination, multisource assessment, project assessment, patient survey, in-house written examination, in-training examination, oral exam, objective structured clinical examination, structured case discussions, anatomic or animal models, role-play or simulations, formal oral exam, practice/billing audit, review of case or procedure log, review of patient outcomes, review of drug prescribing, resident experience narrative and any other applicable assessment method

Examples of types of evaluators: self, program director, nurse, faculty supervisor, medical student, faculty member, allied health professional, resident supervisor, patient, other residents, technicians, clerical staff, evaluation committee, consultants

Competency Assessment Method(s) Evaluator(s)

Patient Care

Medical Knowledge

Practice-based learning & Improvement

Interpersonal & Communication Skills

Professionalism

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Competency Assessment Method(s) Evaluator(s)

Systems-based Practice

4. Describe how evaluators will be educated to use the assessment methods listed above so that residents are evaluated fairly and consistently.

Limit your response to 400 words.

5. Describe how residents will be informed of the performance criteria on which they will be evaluated.


6. Describe the system that ensures that faculty will complete written evaluations of residents in a timely manner following each rotation or educational experience.


7. Describe the process that will be used to complete and document written semiannual resident evaluations, including the mechanism for reviewing results of the evaluation (e.g., who meets with the residents and how the results are documented in resident files).


8. Describe the system that residents will use to provide annual confidential written evaluations of the teaching faculty. [The answer must include evaluations at least once per year, the steps taken to maintain confidentiality, and the process by which evaluations are sought.]


9. Describe the system that the program (or department, if applicable) will use to provide evaluation and feedback to the teaching faculty.


10. Describe the approach that will be used for program evaluation, including how the program will ensure that residents provide confidential written evaluation of the program at least annually.


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F. RESIDENT DUTY HOURS

1. Excluding call from home, what is the projected average number of hours on duty per week per resident?

2. What is the projected average number of days per week of in-house call (excluding home call and night float) which residents will be assigned?

3. How will the faculty provide appropriate supervision of residents in patient care activities?

4. How will the program ensure that residents comply with the ACGME duty hour standards? Be specific as regards the duty hour weekly limit, time spent on-call, days free each week, length of duty shifts, periods of rest between duty shifts, and moonlighting policies, as applicable.

5. How will the program ensure that residents recognize the signs of fatigue and sleep deprivation?

6. How will the program ensure that resident education is not adversely affected by heavy service obligations?

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G. RESIDENTS’ SCHOLARLY ACTIVITIES

Will the program offer residents the opportunity to participate in scholarly activities? If yes, briefly describe the opportunity and the expectations about residents’ participation. [The answer must include which research skills are taught in the curriculum.]

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COMMON SUBSPECIALTY PROGRAM INFORMATION FORM

H. FACULTY RESEARCH

1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary.

# of current IRB

approved research projects

Total # of current funded

research projects

# of current research projects with peer review

funding (subset of total # in previous

column)

# presentations at national scientific

meetings in the last 5 years

# publications in peer review journals in the

last 5 years

Program Director:

Key Faculty:

Fellow Research Mentors Who Are Not Key Faculty:

2. List active research projects in the subspecialty.

Project title Funding source

Put an “X for funding awarded by peer review

process

Years of funding (dates)

Faculty investigator and role in grant (i.e. PI, Co-PI,

Co-investigator)

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I. RESEARCH RESOURCES

1. Does the program provide research laboratory space and equipment? (if appropriate)................................................................................................................................( ) YES ( ) NO

2. Does the program provide financial support for research?.....................................( ) YES ( ) NO

3. Does the program provide computer and statistical consultation services?...........( ) YES ( ) NO

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J. PROGRAM CURRICULUM

1. Block Diagram

The purpose of a block diagram is to give the Residency Review Committee an overview of what takes place during each year of training.

EXPERIENCES OF ROTATIONS In each one month or 4 week block indicate the following:

(1) the learning activity (i.e., Trauma) or vacation, (2) percentage of clinical (C) and research (R) time (i.e., 50% C; 50% R)(3) the site in which the activity occurs (i.e., HOSP1, HOSP 2 or OTHER – clinical site or office) as designated in Section 2 of this form.

Provide a key/legend for the abbreviations used (i.e., ED = Emergency Department),

DUTY HOURS In the row requesting duty hours, report (1) the usual number of hours/week worked and (2) the longest consecutive hours during that

week. Indicate whether call is call from home (H) or in-house call (IH). Asterisk the rotations that are call free.

ExampleMonth/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13

Experience or rotations

ED100% (C)HOSP1

ED100%

(C) HOSP1

ED100%

(C) HOSP1

Anes100% (C) HOSP1

Trauma100%

(C)HOSP2

ELEC100%

(C) HOSP1

ELEC100%

(C) HOSP1

ELEC100%

(C) HOSP2

Research

20% (C)80% (R)HOSP1

Research 100%

(R) HOSP2

Research

100% (R) HOSP1

VAC N/A

Duty Hours70/20

IH70/10

IH70/10

IH80/24

IH85/30

IH70/30

IH70/30

IH80/30

H60/20 * 60 * 60 *

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FIRST YEAR BLOCK DIAGRAMMonth/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13


Duty Hours

SECOND YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13


Duty Hours

THIRD YEAR BLOCK DIAGRAM Month/4wk 1 2 3 4 5 6 7 8 9 10 11 12 13


Duty Hours

Total number of clinical months _____________

Total number of research months ____________

If there are any exceptions to the fellowship program as outlined above for any of the current fellows, describe these exceptions below (Insert text in box.):

Limit response to 50 words

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2. Goals and Objectives

A complete set of goals and objectives must be available for the site visitor. Choose as a sample the goals and objectives for one clinical rotation and attach it to the PIF as Appendix A (do not append all of the goals and objectives). For new applications, submit the complete set of goals and objectives.

Place an ‘X” in the box before the applicable response.

Are there goals and objectives for all training experiences?

( ) YES ( ) NO

Are they rotation and level specific? ( ) YES ( ) NO

How are they distributed? ( ) Hard Copy ( ) Electronic or web-based

If not web-based, when are they distributed to fellows?

( ) Prior to Each Rotation ( ) Annually ( ) Once in Handbook ( ) Other

If not web-based, when are they distributed to faculty?

( ) Prior to Each Rotation ( ) Annually ( ) Other

If web-based, do you send out reminders to access them?

( ) YES ( ) NO

If yes, when do you send them?

3. Collaboration between Programs

Are there meetings among the core Program Director and subspecialty Program Directors?

( ) YES ( ) NO If yes, have minutes available for site visitor confirmation

How often do these meetings occur?

Who is typically involved in these meetings? (check all that apply)

( ) Core program director( ) Subspecialty program director for this specialty ( ) Program directors from other subspecialties

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4. General Subspecialty Curriculum

Topic

Where Taught in Curriculum?

(Name should match name in conference list)

Number of Structured

Teaching Hours Dedicated to Topic

Area?

Participants(place and X in the appropriate

column)

Fellows in this

DisciplineAttend

All Subspecialty

FellowsAttend

Residents & Subspecialty

Fellows Attend

e.g., Biostatistics Research Course 14 X

Basic science as related to the application in clinical subspecialty practice

Clinical subspecialty content

For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for fellows in developmental and behavioral pediatrics), enter N/A into column 1.

Biostatistics

Lab research methodology (if appropriate)

Clinical research methodology

Study design

Grant preparation

Preparation of protocols for institutional review board

Principles of evidence-based medicine/ Critical literature review

Quality Improvement

Teaching skills

Professionalism/Ethics

Cultural Diversity

Systems-based practice (economics of healthcare, practice management, clinical outcomes, etc.)

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5. Conferences

Have Conference Schedule Available For Review By Site Visitor. Do Not Append Conference Schedule.

a) List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the subspecialty training program. Identify the "SITE" by using the corresponding number as appears on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and whether conference attendance is required (R) or optional (0). List the role of the fellow in this activity. (e.g., conducts conference, presents case and participates in discussion, case presentation only, participation limited to Q&A component, etc.)

Conference Site # Frequency R/O Role of the Fellow

b) Describe the mechanism that is used to assure fellow attendance at required conferences. State the degree to which faculty attendance is expected, and how this is monitored.


6. Scholarship Oversight Committee

a) Is there a scholarship oversight committee for every fellow?.........................( ) YES ( ) NO If yes, have names of committee members for each fellow available for site visitor confirmation.

b) How often does the committee meet with the fellow?...............................# ( ) times per year

7. Fellow Research Activities

a) Describe how the program ensures a meaningful supervised research experience for the fellows, beginning in their first year and extending throughout their training.

b) If faculty outside the division are actively involved in mentoring the fellows, list and provide details.

c) List the scholarly activities (publications, presentations ((local, regional, national meetings)), grants, and other scholarly work products) for each of the current fellows in the program and for the fellows who completed the program since the last ACGME site visit. Begin by listing the fellow’s name and years in the fellowship program. For each scholarly activity, note the faculty mentor’s name.

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Example:

Doe, John (2008 – present)Doe, JJ, Smith JS. Circulating microspheres to determine resident duty hours. Acad Med. 2010;55:155 (Mentor JS Smith)

Doe JJ, Smith JS, Jones TJ. Genetic mutations in resident occurring after working 16 hours. Poster platform presentation at PAS 2010, Vancouver. (Mentor: JT Jones)

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PROGRAM INFORMATION FORM - PEDIATRIC NEPHROLOGY

PERSONNEL, FACILITIES AND RESOURCES

A. Support Services

List the clinical training settings/experiences and for each, indicate with a check mark the personnel who interact regularly with fellows.

Setting

Related Disciplines

Nutrition * Psychology * Social Work*Dialysis Support

Staff*

* appear as “must” in the requirements

For categories of personnel that are unavailable, describe how that function is addressed in the program.

B. Facilities

Indicate the availability of the following:

Facility/Service Site 1 Site 2 Site 3CRRT facilities (yes/no)Dialysis unit (yes/no)Space in an ambulatory setting for evaluation and care of patients (yes/no)PICU (indicate total number of beds)NICU (indicate total number of beds)

If “NO” is indicated for any of the service/experiences across all hospitals, explain how the service/experience is provided below.

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C. Services and Laboratories

Site 1(Yes/No)

Site 2(Yes/No)

Site 3(Yes/No)

Pathology Service:Are there pathologists with experience/training in pediatric renal pathology?Do the fellows have an opportunity to participate in review and interpretation of renal biopsy specimens?

Diagnostic Services:Comprehensive diagnostic imaging Electron microscopyImmunologyImmunopathologyHistocompatibilityRadionuclide laboratory

If “NO” is indicated for any of the service/experiences across all hospitals, explain how the service/experience is provided below:

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I. PATIENT CARE

A. Patient Data

Provide the following information for the most recent 12-month academic or calendar year for each hospital that fellows rotate on the pediatric nephrology service. Note the same timeframe should be used throughout the forms.

Inclusive Dates: FROM: (mm/dd/yy) TO: (mm/dd/yy)Site 1 Site 2 Site 3

Total number of admissions to the Pediatric Nephrology serviceNumber of new patients admitted each year (“new” refers to those who are seen by members of the Pediatric Nephrology service for the first time.)Average length of stay of patients on the Pediatric Nephrology service Total number of consultations by pediatric Pediatric Nephrologists on other inpatients

Number of consultations provided to the NICUNumber of consultations provided to the PICU

Average daily census of patients on the Pediatric Nephrology service, including consultationsNumber of patients requiring follow-up care by Pediatric Nephrology service as outpatients during 12-month period reported

If applicable, provide the following information for the most recent 12-month academic or calendar year for each hospital used to provide a specific required experience, such as transplant, cardiology, intensive care, etc. Note the same timeframe should be used throughout the forms. Duplicate this table as necessary.

Inclusive Dates: FROM: (mm/dd/yy) TO: (mm/dd/yy)Site 1 Site 2 Site 3

Name of service:Total number of fellows and residents on the serviceTotal number of admissions to the serviceNumber of new patients admitted each year (“new” refers to those who are seen by members of the service for the first time.)Average length of stay of patients on the service Average daily census of patients on the service, including consultations

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B. Ambulatory Pediatric Nephrology Experience for All Years of Training for New Applications

For New Applications: Indicate projected numbers for fellows:

Name of ExperienceHospital/Other Setting Identifier

Duration of Experience(in wks/yr)

Number of Sessions Per

Week Per Fellow

Number of New Patients Per Fellow Per

Session

Number of Return Patients Per Fellow Per

Session

Average Number

Teaching Attendings Per

Session

If the experience is in a private office, provide full details, including name and credentials of supervisor, numbers and types of patients, degree of fellow responsibility for their care, frequency of attendance at office, how director monitors the experience and fellow performance.

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C. 12-Month Summary - Inpatient Services

Summarize how many pediatric patients with the following nephrology problems were admitted to or consulted on by the Nephrology service at the primary hospital. This should cover the same 12-month period used in previous sections. For all consults seen by fellows, indicate location (Regular inpatient ward, NICU or PICU). For new applications, fill in only the first two columns.

Hospital Name:Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy):

Primary Renal Disorders

Total number of patients: Number seen by fellows:# on Nephrology

service# seen in

consultation# on Nephrology

service# of

consultationsPerinatal and neonatal conditions including congenital anomalies of the kidneys and genitourinary tractHypertensionAcute kidney injury Chronic kidney disease and end-stage renal diseaseUrinary tract infections, voiding dysfunction, nephrolithiasis, and urologic disordersRenal transplantationFluid and electrolyte and acid base disordersAcute and chronic glomerular diseasesInherited renal disorders:

genetic syndromes tubular disorders cystic diseases

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D. 36 Month Summary: Patient Procedures

Provide patient data for the most recent 36 month period for which records can be obtained. Indicate the number available of the following at each of the hospitals participating in the program.

Inclusive Dates: From (mm/dd/yy): To (mm/dd/yy):Site 1 Site 2 Site 3

Dialysis:Total number of new and chronic dialysis patients cared for by the pediatric service in the past 3 years:

Hemodialysis Peritoneal dialysis

Total number of acute dialysis treatments performed in the past 3 years:

Acute renal injury Toxin removal

Total number of patients that fellows are exposed to that utilize home dialysis treatment modalities:Renal Transplantation:Total number of patients who have undergone transplantation in the past 3 years:New Renal Transplantation

Living related donor Deceased donor

Other Procedures:Patients started on Continuous Renal Replacement TherapyRenal Biopsy

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E. List of Diagnoses

List 150 CONSECUTIVE admissions and/or consultations to the Pediatric Nephrology service. Identify the time period during which these admissions/consultations occurred. The date range should occur within the same 12-month period used in previous sections. The dates must begin on the date the first patient on the list was admitted and end with the date the 150th patient was admitted, e.g., July 1, 2007 through October 20, 2007. Submit a separate list for each hospital that provides required rotations. Use additional pages as necessary.

Hospital:Give inclusive dates during which these admissions/consultations occurred:

From (mm/dd/yy): To (mm/dd/yy):

Patient ID Number of days in hospital

Nephrology Diagnosis(may include secondary diagnosis if relevant)Number Age

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II. MEDICAL KNOWLEDGE

A. Core Curriculum: Specialty Experiences

Identify the learning activities (clinical experience, conference series, journal club, etc.) and training sites (hospital #) used to address the required core knowledge area.

Core Knowledge AreaList in Bulleted Format the Learning Activities

Used to Address the Core Knowledge/Skill

List the Corresponding Setting in Which These Learning Activities

Take PlaceYear(s) of Training

Other Core Curricular AreasCongenital Anomalies of the Kidneys and Genitourinary Tract

Hypertension Acute Kidney Injury Chronic Kidney Disease and End-Stage Renal Disease

Urinary Tract Infections Voiding Dysfunction Nephrolithiasis Urologic Disorders Fluid and Electrolyte and Acid Base Disorders

Acute and Chronic Glomerular Diseases

Renal Development Renal Physiology and Pathophysiology

Renal Immunopathology Renal Cell and Molecular Biology and Genetics

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B. Inpatient Experiences

What responsibilities do the fellows have for inpatients and how and by whom are they supervised when assigned to inpatient services?

C. Outpatient Experiences

1. What responsibilities do the fellows have for outpatients and how and by whom are they supervised during the provision of outpatient care?

2. Describe how the program ensures that fellows provide continuity of care for a panel of patients throughout training and to what extent do fellows have the opportunity to provide outpatient care for patients whom they treated on the inpatient service?

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Describe the planned program learning activities which will provide experience in the general competencies for residents. Examples of learning activities include: didactic lecture, assigned reading, seminar, self-directed learning module, conference, small group discussion, workshop, online module, journal club, project, case discussion, one-on-one mentoring.

III. PRACTICE-BASED LEARNING AND IMPROVEMENT (PR IV.A.5.c))

1. Describe one learning activity in which residents will engage to identify strengths, deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set learning and improvement goals; identify and perform appropriate learning activities to achieve self-identified goals (life-long learning).


2. Describe one learning activity in which residents will engage to develop the skills needed to use information technology to locate, appraise, and assimilate evidence from scientific studies and apply it to their patients’ health problems. The description should include:

a) locating informationb) using information technologyc) appraising informationd) assimilating evidence information (from scientific studies)e) applying information to patient care


3. Describe one planned quality improvement activity or project in which at least one resident will participate that will require the resident to demonstrate an ability to analyze, improve and change practice or patient care. Describe planning, implementation, evaluation and provisions of faculty support and supervision that will guide this process.


4. Describe how residents will:

a) develop teaching skills necessary to educate patients, families, students, and other residents;b) teach patients, families, and others; and, c) receive and incorporate formative evaluation feedback into daily practice. (If a specific tool is

used to evaluate these skills have it available for review by the site visitor.)


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5. Describe the process for mentoring the fellows. Address the following items for each type of mentor if more than one is assigned to each fellow (i.e., if there is a separate research mentor). Describe (1) how mentors are selected, (2) how often the mentor meets with the mentee and (3) the guidelines that are provided for topics to be addressed during meetings between mentors and mentees.


(1)(2)(3)

6. Outline the faculty development activities that are provided for acquainting the faculty with mentoring skills.


7. Learning Plans

Is each fellow required to have an individualized learning plan? (If yes, have learning plans available for site visitor verification.)

( ) YES ( ) NO

Who provides guidance to the fellow in completing this plan (check all that apply)?

( ) No guidance, resident driven ( ) Fellow’s mentor ( ) Program Director ( ) Other (describe)

How often are these plans developed or updated? ( ) Annually ( ) Semi- Annually ( ) Other (describe)

8. List the clinical quality improvement activities in which fellows actively participate and identify who guides them in this process.


9. Using the bulleted list below (add bullets as needed) identify specific ways in which the program fosters reflection, self-assessment, and practice improvement for fellows.


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IV. INTERPERSONAL AND COMMUNICATION SKILLS (PR IV.A.5.d))

1. Describe one learning activity in which residents will develop competence in communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds, and with other physicians, other health professionals, and health related agencies.


2. Describe one learning activity in which residents will develop their skills and habits to work effectively as a member or leader of a health care team or other professional group. In the example, identify the members of the team, responsibilities of the team members, and how team members communicate to accomplish responsibilities.


3. Explain (a) how the completion of comprehensive, timely and legible medical records will be monitored and evaluated, and (b) the mechanism that will be used for providing residents feedback on their ability to maintain medical records.


4. How do fellows learn to achieve competence in conducting a family meeting to deliver critical/complex information about patient diagnosis, prognosis and /or treatment. Answer by using a specific example to illustrate.


5. Describe (1) how the fellow’s written communication (including but not limited to progress notes, consults, and letters to referring physicians) is reviewed and (2) how feedback is given regarding its quality.


(1)(2)

6. Using the bulleted list below (add bullets as needed) identify the specific methods the program uses to ensure that fellows achieve competence in effective communication (verbal & written) in a consultative role with other physicians, health care workers and outside agencies.


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V. PROFESSIONALISM (PR IV.A.5.e))

1. Describe one learning activity, other than lecture, by which residents will develop a commitment to carrying out professional responsibilities and an adherence to ethical principles.


2. How will the program promote professional behavior by the residents and faculty?


3. How will lapses in these behaviors be addressed?


4. Explain how the following contribute to the evaluation of professionalism: (1) patients/families, and (2) members of the health care team.


(1)(2)

5. Using the bulleted list below (add bullets as needed) identify specific methods the program uses to teach and evaluate the elements of professional competence.


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VI. SYSTEMS-BASED PRACTICE (PR IV.A.5.f))

1. Describe the learning activities through which residents will achieve competence in the elements of systems-based practice. Examples of such activities would include: work effectively in various health care delivery settings and systems, coordinate patient care within the health care system; incorporate considerations of cost-containment and risk-benefit analysis in patient care; advocate for quality patient care and optimal patient care systems; and work in interprofessional teams to enhance patient safety and care quality.


2. Describe an activity that will provide experiential learning in identifying system errors.


a. Identify who guides/supervises fellows in this activity.


3. Address how the elements of this competency are taught and how they are evaluated. System errors need not be addressed here.


4. How does your program meet the requirement for exposure to administrative experience in the context of your subspecialty?


5. Give an example of how fellows are expected to navigate the “system”, that is identify/access resources, make referrals, and coordinate services for patients within your subspecialty practice.

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